# Situation: A 78-year-old woman who lives alone is admitted with community-acquired pneumonia. Her daughter reports that she has eaten very little for the past 10 days. Her recorded weights are: 6 months ago, 53.0 kg; 3 months ago, 52.0 kg; 1 month ago, 48.9 kg; today, 46.5 kg. She is 1.55 m tall and has no edema. Nasogastric feeding is ordered. Which measures should the nurse include in her plan for the first days of feeding? 1. Give thiamine before the first feeding. 2. Start at about 10 to 20 kcal/kg/day and advance slowly. 3. Check potassium, magnesium, and phosphate once, before the first feeding. 4. Start at her full estimated needs of 30 kcal/kg/day. 5. Weigh her daily and watch for edema.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630477  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 78-year-old woman who lives alone is admitted with community-acquired pneumonia. Her daughter reports that she has eaten very little for the past 10 days. Her recorded weights are: 6 months ago, 53.0 kg; 3 months ago, 52.0 kg; 1 month ago, 48.9 kg; today, 46.5 kg. She is 1.55 m tall and has no edema.

Nasogastric feeding is ordered. Which measures should the nurse include in her plan for the first days of feeding?
1. Give thiamine before the first feeding.
2. Start at about 10 to 20 kcal/kg/day and advance slowly.
3. Check potassium, magnesium, and phosphate once, before the first feeding.
4. Start at her full estimated needs of 30 kcal/kg/day.
5. Weigh her daily and watch for edema.

## 보기

1. 1, 3 and 4
2. 1, 2 and 5 **✔ 정답**
3. 2, 3 and 5
4. 1, 2 and 3

**정답: 2**

## 해설

She is at high risk of refeeding syndrome because of poor intake for 10 days and significant recent weight loss. The plan gives thiamine 100 mg before feeding and daily for 5 to 7 days, starts at about 10 to 20 kcal/kg/day and advances slowly, and watches daily weight for fluid retention. Potassium, magnesium, and phosphate are checked every 12 hours for the first 3 days, not once before feeding, because they fall after feeding starts.

## 심화 해설

Why she is at high risk of refeeding syndrome
Refeeding syndrome is a dangerous shift of fluid and electrolytes that can occur when nutrition is restarted after a period of starvation. She has eaten very little for 10 days and has lost a significant amount of weight recently, so her intracellular stores of phosphate, potassium, and magnesium are depleted even if her blood levels look normal. When carbohydrate is reintroduced, insulin rises and drives glucose, phosphate, potassium, and magnesium into the cells, so serum levels can fall abruptly. The result may be weakness, cardiac arrhythmias, respiratory failure, fluid overload, and confusion.

The three correct measures
Item 1, thiamine before the first feeding, is correct because thiamine is a cofactor in carbohydrate metabolism, and a sudden carbohydrate load can precipitate Wernicke encephalopathy. The plan gives thiamine 100 mg before feeding and daily for 5 to 7 days. Item 2, starting at about 10 to 20 kcal/kg/day and advancing slowly, limits the insulin surge and the electrolyte shift. Item 5, daily weights and watching for edema, detects the sodium and water retention that refeeding can cause. Low and slow feeding, thiamine first, and close monitoring are the core of refeeding prevention.

Why items 3 and 4 are wrong
Item 3 sounds reasonable but is incomplete: checking potassium, magnesium, and phosphate only once before feeding misses the fall that happens after feeding starts. The levels are checked every 12 hours for the first 3 days and replaced as needed. Item 4, starting at her full estimated needs of 30 kcal/kg/day, is exactly the practice that provokes refeeding syndrome in a high-risk client. Watch out! The word "once" in item 3 is the trap; baseline electrolytes are drawn, but monitoring must continue after feeding begins.

| Measure | In the plan? | Reason |
| --- | --- | --- |
| Thiamine before feeding | Yes | Prevents Wernicke encephalopathy when carbohydrate is restarted |
| Start 10–20 kcal/kg/day, advance slowly | Yes | Limits insulin-driven electrolyte shifts |
| Daily weight, watch for edema | Yes | Detects fluid retention |
| Electrolytes checked once only | No | Levels fall after feeding begins; check every 12 hours for 3 days |
| Full needs from day 1 | No | Provokes refeeding syndrome |

Exam takeaway
When a stem describes an older or malnourished client with days of poor intake and recent weight loss, think of refeeding risk before choosing a feeding plan. Key point! Give thiamine before feeding, start at a low rate, advance gradually, and keep monitoring electrolytes, weight, and fluid status after feeding starts.

## 임상 시나리오

Preventing Refeeding SyndromeFirst days of nasogastric feeding
After 10 days of poor intake and significant weight loss, she is at high risk of refeeding syndrome: insulin released with feeding drives phosphate, potassium, and magnesium into the cells, and serum levels fall.

Plan: thiamine 100 mg before feeding and daily for 5 to 7 days; start at 10 to 20 kcal/kg/day and advance slowly; weigh daily and watch for edema.

Check potassium, magnesium, and phosphate every 12 hours for the first 3 days, not just once before feeding.

CautionStarting at full needs of 30 kcal/kg/day in a starved client can cause arrhythmias, respiratory failure, and fluid overload.

## 핵심 개념

- **Refeeding syndrome** — Potentially fatal fluid and electrolyte shifts, especially low phosphate, that occur when feeding is restarted after starvation.
- **Thiamine** — Vitamin B1, a cofactor in carbohydrate metabolism; deficiency triggered by refeeding can cause Wernicke encephalopathy.
- **Hypophosphatemia** — A low serum phosphate level, the hallmark electrolyte disturbance of refeeding syndrome.
- **Wernicke encephalopathy** — An acute brain disorder from thiamine deficiency causing confusion, eye movement problems, and unsteady gait.

## 같은 주제 문제

- [Situation: A 52-year-old man with alcohol use disorder is admitted for poor oral intake. H…](https://mymerci.kr/pages/nclex_q.php?qn_id=630266)
- [Situation: A 52-year-old man with alcohol use disorder is admitted for poor oral intake. H…](https://mymerci.kr/pages/nclex_q.php?qn_id=630267)
- [Situation: A 52-year-old man with alcohol use disorder is admitted for poor oral intake. H…](https://mymerci.kr/pages/nclex_q.php?qn_id=630268)
- [Situation: A 52-year-old man with alcohol use disorder is admitted for poor oral intake. H…](https://mymerci.kr/pages/nclex_q.php?qn_id=630269)
- [Situation: A 46-year-old woman has had heartburn and regurgitation after meals for 6 month…](https://mymerci.kr/pages/nclex_q.php?qn_id=630270)
- [Situation: A 46-year-old woman has had heartburn and regurgitation after meals for 6 month…](https://mymerci.kr/pages/nclex_q.php?qn_id=630271)
- [Situation: A 46-year-old woman has had heartburn and regurgitation after meals for 6 month…](https://mymerci.kr/pages/nclex_q.php?qn_id=630272)
- [Situation: A 38-year-old man comes to the outpatient clinic with epigastric pain for the p…](https://mymerci.kr/pages/nclex_q.php?qn_id=630273)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._